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This application is secure. All submitted information is secured with bank-level encryption to ensure privacy and compliance with federal HIPAA regulations. By completing this referral application, you attest that you are either the client or are authorized by the client to submit personal/protected information to LifeCare Alliance on their behalf. Information collected in this referral application will become part of the client’s file at LifeCare Alliance.

What is the source of this referral?*

Referring Agency

Physician's Office

Self

Family

Your Email Address*

Patient Information

Name*

FirstLast

Date of Birth

Phone*

Address

Street AddressAddress Line 2CityStateZIP Code

Emergency Contact

FirstLast

Emergency Contact Relationship

Emergency Contact Phone

Is the patient a veteran?*

If yes, we will request a copy of patient's DD214.

Yes

No

Unknown

Is the patient a Franklin County Senior Options Recipient?*

Yes

No

Unknown

Case Manager Name

FirstLast

Services Being Received through Franklin County Senior Options

Is the patient a PASSPORT/MyCare Ohio Recipient?*

Yes

No

Unknown

Case Manager Name

FirstLast

Services Being Received through PASSPORT/MyCare Ohio

Does this patient already receive home-delivered meals?*

Yes

No

Unknown

Current home-delivered meal provider

Insurance Information

Primary Insurance

Primary Insurance Member ID #

Primary Insurance Group #

Secondary Insurance

Secondary Insurance Member ID #

Secondary Insurance Group #

Services Being Requested

Diabetic or Nutritional Counseling

Medical Nutrition Therapy (MNT)

Diabetes Self-Management Training (DSMT)

Free or Low-Cost Cancer Screenings

Cancer risk assessments

Skin examinations

Breast examinations

Screening and diagnostic mammograms

Pap tests and pelvic exams

Colon cancer screening tests

Prostate cancer screening tests

Home-Delivered Meals

Please choose only one. Meal customers must be home to receive the delivery and must sign/initial delivery receipt.

Daily Hot

Weekly Frozen

Safety/Wellness Check Only (No Meal Needed)

Daily

Weekly

Other (please specify below)

Other Safety/Wellness Check Frequency

Verifying

Blood Pressure

Blood Sugar

Weight

Other (please specify below)

Other Requested Verification

Report to Referring Agency When:

Supportive In-Home Services

Meal Preparation

Home Repair Assistance

Other Service

Please provide as much detail as possible, explaining service(s) requested.

Services Being Requested

Which LifeCare Alliance services are you seeking?

Meals-on-Wheels

Central Ohio Diabetes Association

Help-at-Home

Wellness Services

Free or low-cost cancer screening or mammogram

Project OpenHand-Columbus

Other (Please Specify)

I Don't Know

Other Services Requested (Please Specify)*

Notes

Patient Medical History

ICD Diagnosis Code(s)

Complete the fields below for Diabetic or Nutritional Counseling only

Most Recent A1C Results

Date of A1C Test

Is Information on Labs and Medications Available for This Client?

LifeCare Alliance will follow up with referring agency for this information.

Yes

No

Referring Physician

Practice Name*

Phone*

Fax

Address*

Street AddressAddress Line 2CityStateZIP Code

PCP/Referring Physician Name*

FirstLast

NPI #

Medicare #

Referring Agency

Name of Referring Agency*

Name of Agency Representative Making Referral*

Relationship to Client*

Phone*

Email*

As the Referring Agency representative, I have communicated the service basics and referral process for the identified LifeCare Alliance services to the patient.*

Yes

No

The patient referenced on this form agrees to proceed with the assessment process for the identified service(s).*

Yes

No

If you answered no to either #1 or #2 above, provide background information so that we may proceed with initiating service:

Referral Source

Name of Person Submitting This Form*

FirstLast

Relationship to Client*

Submit

Your referral submission is almost complete. Please follow any instructions in the reCAPTCHA field below, then click Submit. If you have any questions or concerns about this process, please contact our Customer Service Department at 614-278-3130.

By submitting this form, I hereby consent to the disclosure of the records to the purpose and extent stated. This authorization may be revoked by the client at any time to the extent that disclosure has not already occurred prior to the request for revocation. I understand that in order to revoke this authorization I must do so in writing. I understand that the information used or disclosed as a result of this authorization may be subject to re-disclosure by the person or entity receiving such information.